August 17, 2009

Economist's View - 4 new articles

What do prediction and financial markets have to say about the prospect of dropping the public option and replacing it with health care co-ops? Arin Dube has an answer (which is a follow-up to this post):

Public Option versus "Co-ops": The Market Test, by Arin Dube: President Obama says he is serious about making sure we have a competitive alternative to the private health insurance companies to drive down costs. However, he is now apparently open to the idea of "health co-operatives" that will be regional purchasing pools operating independently of the federal government. How well will these co-ops achieve his stated goals? To assess this, we can start with his own words and those of his subordinates. Well, to be precise, how various investors reacted to these words.

Exhibit A

Exhibit A shows how investors in the Intrade prediction market reacted to signals from the Obama administration on Sunday August 16 that they are willing to ditch the public health insurance option. In the market's assessment, the likelihood of a federally administered health plan passing fell from around 35% to around 20%, the biggest one-day drop since the prediction market started in June.

So as the public option's condition went to critical, and "co-ops" started looking increasingly likely, how did investors in the top 4 private health insurance companies react? As exhibit B shows, champagne bottles were popped.

Exhibit B

On a day when the broader stock market took a hit (dropping 2.2% at the time of writing), these four companies with a combined market cap of $80 billion saw their prices rise an average of 3%. Actually, if you dot the i's and cross the t's in calculating "abnormal returns"** for these four companies, it comes to be 5.8%. All in all, statements by the Obama administration over the weekend helped investors of private health insurance markets make around $4.6 billion.

So, as the market's assessed likelihood of the public option passing dropped by 15 percentage points, share prices rose by around 6 percentage. If you are willing to extrapolate based on this event, going from a public option to "co-ops" would be worth around 40% of the value of these companies, or around $32 billion. This is similar to the results from my previous analysis of how market reacted to announcements by members of the Senate Finance Committee.

President Obama may have harsh words for the insurance companies. But those are not the words investors in these companies are paying attention to. They are paying attention to whether President Obama will sign a bill with vague "co-ops" or demand a public option. And the reaction by these investors bodes poorly for "co-ops" fulfilling their role as a serious competitive alternative to private insurance companies.

Arindrajit Dube is an economist at UC Berkeley Institute for Research on Labor and Employment who is joining the Department of Economics at the University of Massachusetts, Amherst. His work focuses on labor and health economics topics, as well as political economy.

One is substantive: to have a workable system without the public option, you need to have effective regulation of the insurers. Given the realities of our money-dominated politics, you really have to worry whether that can be done — which is a reason to have a more or less automatic mechanism for disciplining the industry.

The second is what the option debate says about Obama.

If progressives had real trust in Obama's commitment to doing the right thing, the administration would have broad leeway to do deals. But the president doesn't command that kind of trust.

Partly it's a matter of style — as many people have noted, he has been weirdly reluctant to make the moral case for universal care, weirdly unable to show passion on the issue, weirdly diffident even about the blatant lies from the right. Partly it's a spillover from his other policies: by appointing an economic team that's Rubin redux, by taking such a kindly attitude to the banks, he has squandered a lot of progressive enthusiasm.

Add in the dealmaking as part of the health care process itself, and progressives can be forgiven for having the impression that Obama (a) takes them for granted (b) is way too easily rolled by the other side.

So progressives have their backs up over one provision in health care reform that's easy to monitor. The public option has become not so much a symbol as a signal, a test of whether Obama is really the progressive activists thought they were backing.

And the bizarre thing is that the administration doesn't seem to get that.

I think there's another factor as well. It's not just that Democrats don't trust Obama's commitment to progressive issues, and it's not simply a matter of style, or a spillover from other appointments, though I do agree these are issues. It's also the sense that the same old right-wing crazies are driving the public debate to a much greater extent than is justified by the last election. This was supposed to be a new era, one where progressive ideas would dominate public policy, not an era where a false charge of "death panels" would dominate the public discourse, and certainly not an era where misrepresentations from the far right extreme would cause the public option to be dropped from the legislation.

Whether the administration simply does not have the political power, lacks sufficient will, doesn't understand the political significance, or what, it's hard for supporters to watch the same political game unfold once again in what was supposed to be a new era in progressive politics. It's a frustrating slap in the face for progressives who support the administration, and it's the sense of powerless against the right-wing false message machine that is driving that frustration.

The administration needs to take a stand against something important - and win. And not just for what is signals to supporters. Compromise will never appease the crazies on the right, strength is the only way to beat them.

Without a public, Medicare-like option, health care reform is a bandaid for a system in critical condition. There's no way to push private insurers to become more efficient and provide better value to Americans without being forced to compete with a public option. And there's no way to get overall health-care costs down without a public option that has the authority and scale to negotiate lower costs with pharmaceutical companies, doctors, hospitals, and other providers -- thereby opening the way for private insurers to do the same.

It's been clear from the start that the private insurers and other parts of the medical-industrial complex have hated the idea of the public option, for precisely these reasons. A public option would cut deeply into their current profits. That's why they've been willing to spend a fortune on lobbyists, threaten and intimidate legislators and ordinary Americans, and even rattle Obama's cage to the point where the Administration is about to give up on it.

The White House wonders why there hasn't been more support for universal health care coming from progressives, grass-roots Democrats, and Independents. I'll tell you why. It's because the White House has never made an explicit commitment to a public option. ... If Obama tells Senate Democrats he will not sign a healthcare reform bill without a public option, there will be enough votes in the United States Senate for a public option.

I urge you to make it absolutely clear to everyone you know, everyone who cares about universal health care and what it will mean to our country, that the bill must contain a real public option. Tell that to your representatives in Congress. Tell that to the White House. If you are receiving piles of emails from the Obama email system asking you to click in favor of health care, do not do so unless or until you know it has a clear public option. Do not send money unless or until the White House makes clear its support for a public option.

This isn't just Obama's test. It's our test.

I'm not sure this is the place for the administration to take a stand, perhaps it is, but I am sure that they need to take stand on something. Let me ask a question. Can you articulate with a simple statement what the administration's primary goal for health care reform is? Is it to make coverage universal? To control costs and reduce future deficits? To stop the insurance companies from taking advantage of people who already have coverage? All of the above? Something else? I don't think you can take a solid stand on the issues until you've clearly articulated the main goal, and that has not been done. I suspect that the goals will be defined after reform is passed - if it is - and the goals will be defined as whatever they were able to get. We got the main things we were after we will be told, whether that is true or not. But if, in the end, reform is mostly cosmetic, I don't think that strategy will work.

To say that your goal is whatever you can achieve, whatever that is, would be fine if what is possible is independent of how clearly and forcefully the administration articulates its goals, but what can be achieved is not independent of the administration's articulation of its goals. When the goals are vague, it allows the other side to define reform, and do so on their terms and with their terminology, and that limits the possibilities that are available, perhaps fatally.

If health care reform happens, it looks like it will be "Swissified." Like the cheese, it has some holes, but gets the job done:

The Swiss Menace, by Paul Krugman, Commentary, NY Times: It was the blooper heard round the world. In an editorial denouncing Democratic health reform plans, Investor's Business Daily tried to frighten its readers by declaring that in Britain,... the handicapped physicist Stephen Hawking "wouldn't have a chance," because the National Health Service would consider his life "essentially worthless."

Professor Hawking, who was born in Britain, has lived there all his life, and has been well cared for by the National Health Service, was not amused. ...

Investor's Business Daily would like you to believe that Obamacare would turn America into ... a dystopian fantasy version of Britain. The screamers on talk radio and Fox News would have you believe that the plan is to turn America into the Soviet Union. But the truth is that the plans ... would, roughly speaking, turn America into Switzerland — which may be occupied by lederhosen-wearing holey-cheese eaters, but wasn't a socialist hellhole the last time I looked. ...

Every wealthy country other than the United States guarantees essential care to all its citizens. There are, however,... three main approaches...

In Britain, the government itself runs the hospitals and employs the doctors. We've all heard scare stories about how that works...; these stories are false..., over all it appears to provide quite good care while spending only about 40 percent as much.... By the way, our own Veterans Health Administration, which is run somewhat like the British health service, also manages to combine quality care with low costs.

The second route to universal coverage leaves the actual delivery of health care in private hands, but the government pays most of the bills. That's how Canada and, in a more complex fashion, France do it. It's also [how]... Medicare...[does it]... Again, you hear a lot of horror stories about such systems, most of them false. ... And Medicare is highly popular, as evidenced by the tendency of town-hall protesters to demand that the government keep its hands off the program.

Finally, the third route to universal coverage relies on private insurance companies, using a combination of regulation and subsidies to ensure that everyone is covered. Switzerland offers the clearest example: everyone is required to buy insurance, insurers can't discriminate based on medical history or pre-existing conditions, and lower-income citizens get government help...

Massachusetts health reform more or less follows the Swiss model; costs are running higher than expected, but the reform has greatly reduced the number of uninsured. And the most common form of health insurance in America, employment-based coverage, actually has some "Swiss" aspects:... employers have to follow rules that effectively rule out discrimination based on medical history and subsidize care for lower-wage workers.

So where does Obamacare fit into all this? Basically, it's a plan to Swissify America, using regulation and subsidies to ensure universal coverage.

If we were starting from scratch we probably wouldn't have chosen this route. True "socialized medicine" would undoubtedly cost less, and a straightforward extension of Medicare-type coverage to all Americans would probably be cheaper... That's why I and others believe that a true public option competing with private insurers is extremely important: otherwise, rising costs could all too easily undermine the whole effort.

But a Swiss-style system of universal coverage would be a vast improvement on what we have now. And we already know that such systems work.

So we can do this. At this point, all that stands in the way of universal health care in America are the greed of the medical-industrial complex, the lies of the right-wing propaganda machine, and the gullibility of voters who believe those lies.